EuHEA Seminar Series 2021

The EuHEA seminar series brings together health economists all across its member associations, and beyond, to discuss cutting-edge research

EuHEA Seminar Series 2021

The EuHEA virtual seminar series aims to foster exchange between health economists across different countries and institutions and present cutting-edge research in all areas of health economics. A Scientific Committee chaired by Geir Godager (University of Oslo) and Pedro Pita Barros (Universidade Nova de Lisboa) coordinates the series this spring. The seminars take place on Thursdays, 2-3pm, see the detailed program below.

In order to participate in the seminar series, please register here.

Please note that the seminars will not be recorded.

 

Upcoming event

11 March 2021, 14:00-15:00 (CET)

Quality provision in hospital markets with demand inertia: The role of patient expectations

Link to online version of the paper

Luís Sá, University of Minho

Objectives: Switching costs and persistent patient preferences generate demand inertia and link current and future choices of hospital. If the choices patients make are intertemporally linked, these choices will be affected by whether patients anticipate the future, as well as the degree of sophistication of their foresight. Motivated by this observation, we investigate the effect of patient expectations (whether and how patients anticipate the future) on quality provision.

Methods: We develop a two-period spatial model of hospital competition, where demand inertia results from both persistent patient preferences and switching costs. Hospitals are assumed to be "motivated", and we allow for either cost substitutability or complementarity between quality and output. We consider three types of expectations. Myopic patients choose a hospital based on current variables alone; forward-looking but naive patients take the future into account, but assume that quality remains constant; and forward-looking and rational patients correctly foresee the evolution of quality.

Results: We first show that patient expectations affect quality provision through the responsiveness of demand to quality, with higher responsiveness leading to higher provision. Then, we rank quality provision and show that it is higher under naive than myopic expectations, while quality under rational expectations may be highest, lowest, or lie in between. We also show that only under rational expectations may quality be lower than in the counterfactual case of a market without inertia and policies aimed at reducing switching costs beneficial.

Discussion: Discussions of the role of rationality commonly focus on the idea that deviations from fully rational behaviour make consumers act not in their best interest and that firms may find it beneficial to exploit those deviations. Our results indicate that the reverse might as well hold in hospital markets, as our quality ranking also holds for patients’ health gains. When a unilateral increase in current quality yields a reduction in the future quality difference, rational patients foresee its effect on their total expected utility. They are, thus, less sensitive to quality than they would be if they ignored the future. Myopic and naive patients, differently, are oblivious to the future quality reduction and hence overestimate the impact of the current quality increase on their total utility, which leads to higher demand responsiveness and induces hospitals to invest in quality. In this case, therefore, the departures from rationality insulate patients from inferior quality provision by hindering the hospitals’ ability to exploit the otherwise lower demand responsiveness

Chair: to be announced

Discussant: Oddvar Kaarbøe, University of Oslo

Program

11 February 2021, 14:00-15:00 (CET)

Women in Distress: Mental Health and the COVID19 Pandemic

Objectives: The study aims at analysing possible factors affecting women mental wellbeing in the aftermath of the COVID19 first wave. Comparing alternative measures of mental health, we focus on two possible categories of drivers: present concerns and future expectations. The former are defined as factors already present in the experience of the respondent (intensity of the outbreak, changes in unemployment status, stay-at-home restrictions), the latter as speculations on future events (future changes in access to care or employment conditions).

Methods: We run a cross-sectional survey in July 2020 on more than 4,000 women aged 20-65 resident in Italy. The selected group is representative of the real population considered on a geographic and demographic basis. Main outcomes are the level of self-assessed mental distress and concerns, while we alternatively study the use of medications and the self-assessed health. The analysis is performed by means of an OLS estimation, where sets of individual covariates are included (socio-demographics, household characteristics, personal and partner’s employment, present concerns, expectations). We provide further insights on the role of expectations performing a heterogeneity analysis over alternative indexes of gender stereotypes to test for the role of a potential mismatch between women’s aspirations and societal expectations.

Results: Present concerns play a minor role compared to expectations on the future. Beside a strong gradient by age group, with younger women being the most affected, main explanatory factors are the fear to lose the job (own/partner) and negative expectations about labor market and access to care. Interestingly, concerns about own employment status in the future prevail over similar concerns for the partner’s condition, meaning that the worst effects on mental health are related to the fear to lose the social status linked to being employed, rather than the mere expected reduction in household income. Other relevant but minor factors are educational attainments, having (underage) children, practicing remote work. More conservative gender norms increase the probability to report a poor mental health status but negatively interact with expectations, with women living in context with stronger stereotypes partially compensating the effect of negative expectations on their mental wellbeing.

Discussion: The unexpected pandemic situation has large effects on the mental wellbeing of individuals, at least for the specific population group of women who are more exposed to adverse consequences in the labor market and generally more affected by mental health distress. Policy makers should consider that expectations seem to be the main responsible for adverse mental health outcomes, defining adequate interventions that go beyond financial supports or the removal of COVID19 restrictions. Interestingly, gender stereotypes end up acting as a coping mechanism to deal with stress about future working life.

Speaker: Emilia Barili, University of Genoa
Discussant: Raf van Gestel, Erasmus University Rotterdam
Chair: Geir Godager, University of Oslo

18 February 2021, 14:00-15:00 (CET)

Factors associated with lockdown opinions during the second national lockdown in France, attitudes toward the end-of year celebrations and the use of digital contact-tracing ‘TousAntiCovid’

Objectives: This study aims to identify the factors associated with 1) lockdown support during the 2nd lockdown in France and plans for end-of-year holidays’ celebrations and 2) the acceptability and the use of the contact-tracing application ‘TousAntiCovid’.

Methods: Between November 20th and 23rd 2020, a cross-sectional study was conducted among a representative sample of the French population. Factors associated with lockdown support are estimated using an ordered logistic regression. Factors associated with preferences regarding the level of restrictions during the end-of year holidays and with plans for holidays’ celebrations are estimated using multinomial logistic models. Factors associated with the current use and the intention to use the ‘TousAntiCovid’ application are estimated using a logistic model and ordered logistic model respectively. Independent variables of interest include COVID-19 perceived threat, perceived benefits/costs of lockdown and of digital contact-tracing, trust in the government, health literacy, time and risk preferences and endorsement of COVID-19 conspiracy beliefs.

Results: Lockdown support is positively correlated with trust in the government and perceived lockdown efficacy while it is negatively correlated with the endorsement of COVID-19 conspiracy beliefs. Respondents perceiving the health impacts of COVID-19 as very serious and the lockdown as effective are less likely to reject the implementation of a lockdown during the end-of-year holidays. Less support for a strict lockdown during the holidays is found among respondents judging the lockdown as too costly. Respondents perceiving the health impacts of COVID-19 as serious, those trusting the government and those with a higher health information appraisal score are less likely to celebrate holidays as usual. Future-oriented respondents and those with a lower willingness to take health risks are also more likely to change their celebrations’ plans compared to previous years.  The use and intention to use the ‘TousAntiCovid’ application are positively correlated with the perceived efficacy and the perceived data privacy of the application while they are negatively correlated with the COVID-19 conspiracy score.

Discussion: Public communication should fight misinformation on COVID-19 that reduce the support to containment measures and decrease the likelihood to use the ‘TousAntiCovid’ application. As lockdown measures might be reinstated in France, public authorities should also communicate around the effectiveness of such measures and reinforce the associated financial aid programs in order to enhance lockdown acceptance among the population. As ‘TousAntiCovid’ is a key part in the French ‘test, trace, isolate’ strategy, public authorities should further communicate on the utility of digital contact-tracing and reinsure the public on the security of data collected in order to increase the adoption of the application.

Speaker: Pauline Kergall, University of Montpellier
Discussant: Antoine Marsaudon, IRDES
Chair: Pedro Pita Barros, Universidade Nova de Lisboa

25 February 2021, 14:00-15:00 (CET)

An App Call a Day Keeps the Patient Away? On the Substitution of Online and In-Person Doctor Consultations

Objectives: The opportunity to consult a doctor online via video calls or chats is a recent phenomenon in health care. Knowledge is scarce regarding how the availability of online consultations affect individuals’ consumption of regular health care services. In this paper, we causally examine to which extent online consultations replace in-person doctor consultations in Swedish primary care. In Sweden, online consultations was a marginal phenomenon before 2016, when a few private companies realized that they could exploit an institutional feature granting them public funding on a fee-for-service basis. In 2018, these companies supplied 5% of all doctor consultations in primary care. If online consultations fully substitute for in-person visits, the effect on health care spending is only a matter of comparing unit costs. In practice, the degree of substitution is limited by several factors. First, some cases require a physical examination, and thus one additional visit. Second, the greater convenience of online contacts might increase the total demand. Third, the online doctors might specialise on patients with mild and transitory conditions, who might not have been treated at all by regular primary care.

Methods: We use administrative data for 2013-2018 covering in-person and online consultations by 19-20 year olds in the two most populous Swedish regions. The major challenge to identification is that unobserved transitory health problems might simultaneously affect the individual’s consumption of online and in-person care. Of the few existing studies on the subject, ours is the first to account for such heterogeneity. We do so by exploiting exogenous variation in patient fees for online visits facing patients at their 20th birthday in a regression discountinuity design. To limit concerns for other confounding factors at the 20th birthday, we compare the jumps in in-person visits around the 20th birthday of birth cohorts that reached the age limit before and after the online market emerged. We use the differential discontinuity as an instrumental variable for the number of online consultations in a fuzzy RD.

Results [preliminary]: Our main estimate suggest that roughly every other online visit replaces an in-person visit. Heterogeneity analyses suggest that the degree of substitution is larger for men than for women.

Discussion: The net effect in these age groups and in these regions is to increase the number of doctor consultations in primary care. This is in line with previous evidence from two US studies and a study from another Swedish region. Online consultations decrease patients’ private costs for seeking care, as no time is spent travelling to the practice or in the waiting room. This greater convenience appears to come at the cost of increasing the moral hazard problem of health insurance.

Speaker: Lina Maria Ellegård, University of Lund
Disscussant: Naimi Johansson, University of Gothenburg
Chair: Tor Iversen, University of Oslo

4 March 2021, 14:00-15:00 (CET)

Devil in the details: How urgency and costs influence the effects of cost-sharing on healthcare service consumption patterns

Objectives: Decision makers frequently use cost-sharing to alleviate pressure on public healthcare budgets. Apart from generating revenue directly, cost-sharing is a means to influence and steer the behaviour of patients to control demand for healthcare services and thereby address moral hazard. The effect of cost-sharing on demand for healthcare services has been heavily studied in the literature, but researchers often apply a macro-perspective on these issues, opening the door for the fallacy of assuming uniform demand reactions across a spectrum of different healthcare services. The aim of this article is to estimate price elasticities of a variety of healthcare services to highlight how they depend on urgency and price.

Methods: We utilise a dataset of pseudonymised longitudinal patient-level data on healthcare service consumption between Q2-2015 and Q2-2017 of three different sickness funds in Austria covering 1,035,177 patients. We estimate the price elasticity of a set of 11 healthcare services differing in urgency and price. We combine matching via entropy balancing and difference-in-differences estimation in a two-stage study design following a reduction in the co-insurance rate by one of the sickness funds from 20% to 10% in Q2-2016. We further test the robustness of our result using different frequencies on the dependent variable and placebo regression.

Results: The reduction of the co-insurance rate led to a small increase in demand for routine ECGs (+1.5%) and a negligible increase for electromyography (+0.1%) over the whole post-treatment period. Only the effect for routine ECG is statistically significant and robust to our sensitivity analyses. For the nine other healthcare services, pre-trends fail the necessary conditions for a difference-in-differences framework.

Discussion: Our results show that price elasticities of different healthcare services depend on their urgency and costs and cast a new light on previous empirical evidence on price elasticity of healthcare services derived without differentiation between services. Routine ECGs and electromyography are two comparatively expensive healthcare services in the outpatient sector. But whereas routine ECGs are often performed during a health check-up and can easily be postponed by patients, electromyography is more urgent and patients do not have discretion over the timing of the healthcare service consumption. For healthcare services that are urgent, low cost or both, we do not find evidence that a change in co-insurance rate affects demand. A limitation to our study is that some of the healthcare services are not frequently consumed and may be prone to distortions by regional or seasonal fluctuations which may cause deviations in pre-trends. In combination with a small effect size, this likely contributes to the comparatively low statistical significance of the findings.

Michael Berger, Medical University of Vienna

Chair: Izabela Jelovac, GATE Lyon-St-Etienne

Discussant: Mikael Svensson, University of Gothenburg

11 March 2021, 14:00-15:00 (CET)

Quality provision in hospital markets with demand inertia: The role of patient expectations

Link to online version of the paper

Objectives: Switching costs and persistent patient preferences generate demand inertia and link current and future choices of hospital. If the choices patients make are intertemporally linked, these choices will be affected by whether patients anticipate the future, as well as the degree of sophistication of their foresight. Motivated by this observation, we investigate the effect of patient expectations (whether and how patients anticipate the future) on quality provision.

Methods: We develop a two-period spatial model of hospital competition, where demand inertia results from both persistent patient preferences and switching costs. Hospitals are assumed to be "motivated", and we allow for either cost substitutability or complementarity between quality and output. We consider three types of expectations. Myopic patients choose a hospital based on current variables alone; forward-looking but naive patients take the future into account, but assume that quality remains constant; and forward-looking and rational patients correctly foresee the evolution of quality.

Results: We first show that patient expectations affect quality provision through the responsiveness of demand to quality, with higher responsiveness leading to higher provision. Then, we rank quality provision and show that it is higher under naive than myopic expectations, while quality under rational expectations may be highest, lowest, or lie in between. We also show that only under rational expectations may quality be lower than in the counterfactual case of a market without inertia and policies aimed at reducing switching costs beneficial.

Discussion: Discussions of the role of rationality commonly focus on the idea that deviations from fully rational behaviour make consumers act not in their best interest and that firms may find it beneficial to exploit those deviations. Our results indicate that the reverse might as well hold in hospital markets, as our quality ranking also holds for patients’ health gains. When a unilateral increase in current quality yields a reduction in the future quality difference, rational patients foresee its effect on their total expected utility. They are, thus, less sensitive to quality than they would be if they ignored the future. Myopic and naive patients, differently, are oblivious to the future quality reduction and hence overestimate the impact of the current quality increase on their total utility, which leads to higher demand responsiveness and induces hospitals to invest in quality. In this case, therefore, the departures from rationality insulate patients from inferior quality provision by hindering the hospitals’ ability to exploit the otherwise lower demand responsiveness

Luís Sá, University of Minho

Chair: to be announced

Discussant: Oddvar Kaarbøe, University of Oslo

18 March 2021, 14:00-15:00 (CET)

Do the guidelines apply to me? - Patient information and physician agency in prenatal diagnostics

Objectives: Patients who are themselves experts have been found to receive care that is systematically different from care provided to non-expert patients. However, the current literature has been unable to ascertain whether the differences are due to expert patients sending less noisy signals about their preferences or health state than non-experts (statistical discrimination theory) or whether experts use their informational advantage to demand better care than non-expert patients (agency discrimination theory). We investigate the extent to which care provided to medically trained mothers is more likely to bypass clinical guidelines intended to ration access to prenatal diagnostic testing (PDT) compared to not medically trained mothers. Moreover, we examine whether a change in guidelines affected the differences in care offered to expert and non-expert patients.

Methods: Our data is linked Danish administrative data on the use of PDT, patients age, gender, ethnicity education and family income from 51,204 mothers aged 33-37 giving birth from 1996 through 2002 and 23,211 mothers giving birth from 2008 through 2018. We use a differences-in-discontinuities design to estimate the difference in the use of pre-natal testing between expert and non-expert patients on the margin of a guideline threshold. We measure baseline preferences as the difference above the threshold, where all patients are offered PDT. Controlling for this baseline difference in preferences, we estimate expert “overuse” as the difference in the differences above and below the threshold. Prior to 2004 the threshold was age based (35 years) and after 2004 risk based (risk >1:300). We use exact matching to compare mothers with similar levels of education and income levels.

Results: We find a 7.4 percentage points overuse difference when the age-based threshold applied. Overall, 70 percent % of the difference in PDT is due to expert “overuse”. Experts and non-expert patients have similar test-rates above the threshold, indicating that the differences below the threshold are not driven by differences in preferences. After the risk-based threshold was introduced, the difference in PDT almost disappears.

Discussion: Expert mothers circumvent clinical guidelines intended to ration prenatal diagnostic testing indicating that the difference between experts and non-experts is due to agency discrimination.

Nis Lydiksen, University of Southern Denmark

Chair: Mathias Kifmann, University of Hamburg

Discussant: Thomas McGuire, Harvard University

25 March 2021, 14:00-15:00 (CET)

Do subsidized nursing homes and home care teams reduce hospital bed-blocking? Evidence from Portugal

Link to online version of the paper

Objectives: Excessive length of hospital stay is one of the leading sources of inefficiency in healthcare. It can be caused by the lack of alternative care arrangements following a hospitalization. When a patient is medically fit to be discharged but requires some form of support outside the hospital (a short stay at a nursing home facility or home help), which is not readily available, the patient cannot be safely discharged. The patient stays at the hospital for a longer period until a safe discharge is possible –a phenomenon called bed-blocking. I investigate whether, and to what extent, the availability of publicly subsidized nursing homes (NH) and teams providing home care (HC) reduces hospital bed-blocking.

Methods: I use data on the universe of inpatient admissions at public hospitals in Portugal between 2000-2015. Portuguese public hospitals have no financial motivation to prolong lengths of stay. My main empirical analysis relies on a triple-differences design comparing the length of stay of individuals at increased risk of bed-blocking and the length of stay of patients not at risk of bed-blocking, before and after the entry of the first NH and HC team in their region of residence. This design exploits two distinct sources of variation. First, it exploits variation across regions and time in the availability of publicly subsidized NH and HC teams, originating from the staggered implementation of a policy reform. Second, it exploits variation between patients, who live in the same region and are admitted to the hospital in the same time period, in their propensity to bed-block, due to the presence of social needs (e.g. lack of family support).

Results: The entry of HC teams in a region reduces the length of stay of individuals at increased risk of bed-blocking by 4 days relative to regular patients –this reduces length of the bed-blocking period, but does not fully eliminate it. Reductions in length of stay upon the entry of NH occur only for patients with high care needs. Importantly, these reductions in bed-blocking do not come at a cost for patients’ health, showing that the bed-blocking period does not entail any meaningful care provision. Finally, the beds freed up by reducing bed-blocking do not remain unoccupied: there is an increase in the number of programmed admissions following the entry of HC teams, highlighting that longer waiting time for elective care are a relevant cost of bed-blocking.

Discussion: These results yield important policy implications. First, NH and HC teams target different patients and should be used as complements. Second, HC teams are more effective than NH at reducing bed-blocking because the average bed-blocker is not sick enough to need a NH. Taken together, my findings provide insights for organizing care delivery to patients with a complex combination of health and social needs.

Ana Moura, Lund University

Chair: Kim Rose Olsen

Discussant: James Gaughan, Center for Health Economics, York

8 April 2021, 14:00-15:00 (CET)

How Distorted Food Prices Discourage a Healthy Diet

Link to online version of the paper

Public policy making for the prevention of diet-related disease is impeded by a lack of evidence on whether poor diets are a matter of personal responsibility or a choice set narrowed by environmental conditions. An important element of the environment are market imperfections in food retail, which may distort relative food prices and lead to suboptimal dietary choices. To identify such market imperfections, we exploit variation in diets across household that have different levels of income and live in different neighborhoods, using a rich dataset on quantities and prices of food purchases in the U.S. and a structural model of dietary choices. We find that distortions in prices are responsible for one third of the gap between the recommended and actual intake of fruit and vegetables. We construct a feasible fiscal intervention to remedy these distortions that makes all consumers better off.

Thijs van Rens, University of Warwick

Chair: Martin Karlsson, University of Duisburg-Essen

Discussant: to be announced

15 April 2021, 14:00-15:00 (CET)

Lifetime Healthcare Expenditures Across Socio-Economic Groups: Wiping Out the Gradient

Link to online version of the paper

Objectives: A negative social gradient affects healthcare expenditures and longevity in opposite directions. Lower socioeconomic groups have higher current healthcare expenditures compared to higher socioeconomic groups, but also lower life expectancy. Since higher socioeconomic groups consume lower healthcare expenditures across a relatively long lifetime, it is unclear whether a negative health cost gradient exists in a lifetime perspective. This paper analyzes lifetime healthcare expenditures across socioeconomic groups using complete health cost data for all individuals in the entire Danish population.

Method: We calculate expected lifetime healthcare expenditures by gender and socioeconomic group, by weighting average healthcare expenditures by the percentage of the population alive to consume healthcare expenditures from age 30 to 100+.

Results: Contrary to existing literature, we find that all socioeconomic groups spend almost an equal amount on healthcare throughout a lifetime, once we account for socioeconomic mortality and healthcare expenditure differences simultaneously. On average, men in the lowest socioeconomic group spend $268,000 on healthcare across a lifetime, while men in the highest socioeconomic group spend $254,000. Meanwhile, females in the lowest and highest socioeconomic groups spend $352,000 and $328,000 respectively. Even though total lifetime healthcare expenditures across socioeconomic groups are near identical, the level of lifetime healthcare expenditures differs by cost component. The lowest socioeconomic group spends most on outpatient hospital care, prescription drugs, and about 20 percentage more on inpatient care compared to the highest socioeconomic group. Conversely, the highest socioeconomic group spends most on primary care physicians, home care plus home nurses, and 21 percentage more in nursing homes. Nonetheless, all socioeconomic differences in lifetime healthcare expenditures across any cost component are insignificant.

Discussion: Socioeconomic spending differences exist across the age dimension in average healthcare expenditures, but once we account for a full array of health costs and the longer average lifespan of those in the highest socioeconomic groups, the gradient vanishes. These findings question the effectiveness of healthcare systems with free universal healthcare as low socioeconomic groups have shorter life expectancies than higher groups even though they have almost equal lifetime healthcare expenditures. By cost component, socioeconomic groups have different average and lifetime spending, which characterize the health challenge facing each socioeconomic groups. The lowest socioeconomic group, for example, spends most on in- and outpatient hospital care, while the highest socioeconomic group spends most on elderly care. We suggest that policymakers leverage these differences to create more effective policies.

Alexander Overdal Kjærsgaard Marin, University of Aarhus

Chair: Julie Riise

Discussant: Miqdad Asaria, LSE Health

Scientific committee

  • Geir Godager, University of Oslo (Chair)
  • Pedro Pita Barros, Universidade Nova de Lisboa (Co-Chair)
  • Stefan Boes, University of Lucerne
  • Dorte Gyrd-Hansen, University of Southern Denmark
  • Tor Iversen, University of Oslo
  • Oddvar Kaarboe, University of Oslo
  • Sverre Kittelsen, Frisch Centre
  • Liza Sopina, University of Southern Denmark